RIAA Intake Packet

1
Date* This field is required.Please enter the date you are filling out the form
Date
Month
Day
Year
2
Student's Name* This field is required.
First Name
Last Name
3
Student's Date of Birth* This field is required.
Date
Month
Day
Year
4
Student's Social Security NumberEnter in format (xxx-xx-xxxx)
5
Current Grade* This field is required.
6
Address:* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Home Phone Number:* This field is required.
Please enter a valid phone number.
8
Language(s) Spoken at Home:
9
Student's Cell Number:
Please enter a valid phone number.
10
Parent's Marital Status:* This field is required.
Please Select
Please Select
Married
Divorced
Separated
Single
Widowed
11
Mother/Guardian's Name:* This field is required.
First Name
Last Name
12
Mother/Guardian's Date of Birth:* This field is required.
Date
Month
Day
Year
13
Mother/Guardian's Address:Only if Different from Above
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
14
Mother/Guardian's Email:* This field is required.
example@example.com
15
Mother/Guardian's Cell Number:* This field is required.
Please enter a valid phone number.
16
Mother/Guardian's Work Number:This will only be used in case of emergency
Please enter a valid phone number.
17
Father/Guardian's Full Name:
First Name
Last Name
18
Father/Guardian's Date of Birth:
Date
Month
Day
Year
19
Father/Guardian's Address:Only if Different from Above
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
20
Father/Guardian's Email:
example@example.com
21
Father/Guardian's Cell Phone Number:
Please enter a valid phone number.
22
Father/Guardian's Work Number:This will only be used in case of emergency
Please enter a valid phone number.
23
Type the Name of the Group Home
24
Group Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
25
Group Home Contact Person:
First Name
Last Name
26
Group Home Phone Number:
Please enter a valid phone number.
27
Does your child have any allergies or medical conditions? * This field is required.Please enter all allergies and medical conditions, if the student has none, please enter N/A
Huge
Large
Normal
Small
Ok
Ok
28
Emergency Medical Treatment* This field is required.I hereby authorize the Rhode Island Alternative Academy staff, Parent/Guardian and/or designee, to transport, or order transportation for, my child. In the event emergency treatment is necessary. I understand that my child will be taken to the nearest medical facility where the attending physician will assume responsibility for his/her medical care. I understand that I will be notified by telephone and placed in contact with the medical personnel at which point I shall assume full responsibility for the treatment of my child.
I hereby authorize; type Parent/Guardian Name:
My child; type Student's Name:
29
Emergency Medical Treatment Acknowledgement:* This field is required.By signing this document below, I acknowledge the information I choose in the previous section labeled "Emergency Medical Treatment"
Clear
30
Who to Call or Pickup in the Event of Emergency/Illness:* This field is required.Listed below are the name(s) of individuals who I authorize to pick my child up and/or be contacted in case of emergency or illness, from the Rhode Island Alternative Academy .
31
Do you give your consent for your student to be photographed for various school projects?* This field is required.Included but not limited to field trips, class activities etc., and they the photographs could be used on social media, our website, or advertisements.
YESNO
32
Do you give your student permission to be transported by the Rhode Island Alternative Academy throughout the school year for educational purposes as needed?* This field is required.Please note: All of the drivers of the RIAA vehicle have their chauffer's license.
YESNO
33
Do you give permission for your student to access the internet for educational purposes? * This field is required.The Internet represents a unique opportunity for students to explore information that enhances learning. The Internet also has some resources that are not appropriate for young people. We believe benefits outweigh negatives but we are aware that there are some resources we would not want our students to investigate. To reduce the risk of students accessing inappropriate Internet sites, we use an internet site filtering system. The Rhode Island Alternative Academy is committed to helping student use the Internet responsibly but it is not possible to monitor student usage at all times. Students will have opportunities to connect with the internet for classroom assignments and for recreational opportunities under the supervision of teachers. Students will be instructed on the appropriate use of technology in the classroom and recreation activities. Also, staff will provide supervision during usage. To ensure the responsible use of the internet, all students who use the internet are required to adhere to Rhode Island Alternative Academy policies. All students are required to review the policies and sign an Internet Usage Privilege Contract. Any violation of use will result in the loss of a student’s privilege to access the Internet. The Rhode Island Alternative Academy will be providing an iPad, desktop, laptop, or Chromebook computer for use by your son/daughter to complete assignments and to access the internet. By signing this form you agree to allow your child the use of Rhode Island Alternative Academy computers. You are also agreeing that if you child breaks or destroys any computer, you will pay an equal amount to replace the computer. We hope students will share with their parents/guardians some of the exciting Internet projects in which they are engaged in during the school year. Rhode Island Alternative Academy is providing you with information regarding the internet and notifying you that with written consent, your child will be able to access the Internet. If you permit your child use of the Internet you must fill out the information below and return this form to the director at your earliest convenience. Please contact the school office at if you would like further information.
YESNO
34
Do you give your student permission to interact with our Therapy Dog, Clover?* This field is required.Rhode Island Alternative Academy has a fulltime therapy dog on staff. Morgan Deschene, our school social worker, and Clover are a credentialed pet assisted therapy team. Clover is a small sweet rescue pup who loves to be around children and adults. Clover is here to help reduce stress and anxiety, and also bring some fun to our school days. Clover will work with Mrs. Deschene in clinical sessions for grades 7-12 and will occasionally visit the elementary students in grades 1-6. This signed parental permission slip is required to interact with Clover in clinical sessions and throughout the school.
Please Select
Please Select
Yes, I DO give permission for my child to participate in therapy dog visits at Rhode Island Alternative Academy and
my child does NOT have a dog allergy.
My child has a dog allergy but may interact in a limited way with the therapy dog.
No, I DO NOT give permission for my child to participate in therapy dog visits at Rhode Island Alternative Academy.
35
Crisis Intervention and Therapeutic Physical InterventionPlease review the document carefully and download or print if needed. You will be asked to acknowledge your receipt and understanding of this information on the next page.
36
Crisis Intervention and Therapeutic Physical Intervention Acknowledgement:* This field is required.I acknowledge that I have reviewed and received a copy of the Crisis Intervention and Therapeutic Physical Restraint Guidelines. I confirm that I have been given a presentation of each section contained within the handbook and guidelines. I acknowledge that I am aware of and understand the Rhode Island Alternative Academy policies, procedures and rules, including those dealing with “zero tolerance”, crisis intervention and therapeutic physical restraint.. I confirm that I have been given a presentation of each section contained within the handbook and guidelines. I acknowledge that I am aware of and understand the Rhode Island Alternative Academy policies, procedures and rules, including those dealing with “zero tolerance”, crisis intervention and therapeutic physical restraint.
Clear
37
RIAA School Illness PolicyPlease review the attached policy and download or print for your reference.
38
RIAA School Illness Policy Acknowledgement* This field is required.I acknowledge that I have reviewed and received a copy of the RIAA School Illness Policy.
Clear
39
RIAA Clinical Availability PolicyI acknowledge that I have reviewed and received a copy of the RIAA Clinical Availability Policy
40
RIAA School Clinical Availability Policy Acknowledgement* This field is required.I acknowledge that I have reviewed and received a copy of the RIAA Clinical Availability Policy.
Clear
41
RIAA School Policy & ProceduresPlease review this very carefully as it talks about what students can expect at check-in and during the school day.
42
RIAA School Policy & Procedures Acknowledgement* This field is required.I acknowledge that I have reviewed and received a copy of the RIAA School Policy & Procedures.
Clear
Should be Empty: